Persistent Sinus Thrombosis Caused By Superior Sagittal Sinus Stenosis Following an Open Depressed Skull Fracture

Case Report

Austin Neurosurg Open Access. 2016; 3(1): 1044.

Persistent Sinus Thrombosis Caused By Superior Sagittal Sinus Stenosis Following an Open Depressed Skull Fracture

Huseyin Ozevrena* and Adnan Cevizb

Departments of Neurosurgery, Dicle University School of Medicine, Turkey

*Corresponding author: Huseyin Ozevren, Departments of Neurosurgery, Dicle University School of Medicine, Diyarbakir, Turkey

Received: November 12, 2015; Accepted: February 03, 2016; Published: February 05, 2016


Background: Head injuries caused by falls from height are not uncommon in developing countries due to a lack of safety standards. Herein, a unique case of this injury a tile fragment that penetrated the Superior Sagittal Sinus (SSS) and its surgical management are described.

Case Description: The case of a 17-year-old male with a depressed skull fracture overlying the posterior third of the superior sagittal sinus is presented. Emergent exploration was performed to prevent complications such as infection, sinus thrombosis and delayed development of intracranial hypertension.

Conclusion: Depressed skull fractures overlying the major venous sinuses, particularly in the midline, should always be considered a potential source of sinus injury. Although a compound depressed fracture of the SSS was managed to remove the contaminated wound and bone fragments in spite of the risk of fatal venous hemorrhage, the unique nature of this injury warranted surgical management. This case indicates that, in such a scenario, adherence to neurosurgical principles can ensure a good outcome. Furthermore, an MRI venography is recommended for all patients who have an open depressed skull fracture overlying the SSS because of the potential risk for venous sinus stenosis and thrombosis, which may be developed at a later date.

Keywords: Depressed skull fracture; Tile fragment; 3D-CT reconstruction; Superior sagittal sinus


SSS: Superior Sagittal Sinus; GCS: Glasgow Coma Scale; MRI: Magnetic Resonance Imaging; 3D-CT: Three-Dimensional Computed Tomography


Head injuries are one of the most common causes of mortality and morbidity, particularly in developing countries. They usually manifest as skull fractures involving cranial bones. They are commonly seen after fall from heights, road traffic accidents, physical attacks and other injuries [1,2]. Skull fractures are roughly classified into linear, depressed and compound types. Linear fractures are the most common, followed by depressed skull fractures [3]. Compound fractures may be associated with venous sinus laceration or compression in approximately 10% of cases [4].

Various foreign bodies penetrating the cranium have been described, often requiring operative intervention. However, the management of compound depressed fractures of the Superior Sagittal Sinus (SSS) is generally nonoperative because of the high possibility of death due to uncontrollable bleeding from the venous sinuses [5]. Herein, a unique case of injury (due to a tile fragment causing a depressed skull fracture over the SSS) and its surgical management and follow-up are described.

Case Report

A 17-year-old male presented with a history of fall of a tile fragment from the roof of construction zone with a height of 12 feet three hours prior to presentation. He had a history of transient loss of consciousness. On examination, vital signs were stable. His eyes were opened upon pain, he had no verbal response and he was bilaterally localizing to noxious stimuli with a GCS score of eight (E2V1M5). His pupils were equally round and reactive to light. Laboratory studies revealed electrolytes within normal limits. There was no evidence of anemia, thrombocytopenia or thrombocytosis. Routine coagulation studies, including Prothrombin Time/Internationalized Normalized Ratio (PT/INR) and Partial Thromboplastin Time (PTT) were normal. Further laboratory investigation was performed, accounting for antithrombin III activity, protein C level and activity, protein S (free and total) level and activity, fibrinogen level, activated protein C resistance, anticardiolipin antibody level and prothrombin level. Test results were within normal limits. Computed Tomography (CT) of the brain was normal, but 3D-CT (Three-Dimensional Computed Tomography) reconstruction of the bony windows of the cranial vault showed a depressed skull fracture of the middle occipital bone just anterior to the lambdoid suture (Figure 1). Although bleeding from the SSS posed a problem, the head was positioned appropriately. Continuous saline irrigation was conducted while a burr hole opening and craniectomy were performed around the bone fragment. There was a subgaleal clot around the bone fragment. When the fragment was carefully removed, bleeding occurred from the SSS. The roof of the sinus was reconstructed using inverted dural flaps controlled with Gel foam, Surgical and pressure. The wound was washed and closed in layers over a drain during the operation. This ensured a favorable outcome. The surgical procedure was considered successful (Figure 2), and the patient was awakened from general anesthesia in the operating room. The postoperative period was uneventful, and he had no neurological deficits or evidence of infection or symptoms of raised intracranial pressure at the time of discharge (the tenth day after surgery). No anticoagulant therapy was used in the peri- or postoperative periods. One month after the operation, the patient was re-examined due to a disabling headache and vomiting. Fundoscopy demonstrated bilateral papilloedema, and the follow-up MRI venography showed secondary thrombosis of the middle third of the sagittal sinus and stenosis of the posterior third of the SSS (Figure 3). The patient is currently continuing to receive anticoagulant therapy, antiedema agents and acetazolamide.